Patient Election to Self-Pay for Services: Insurance Waiver

Patient's legal name

First NameLast Name

Patient's date of birth

Date

Patient's address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Name of responsible party

First NameLast Name

Email of responsible party

example@example.com

Phone number of responsible party

Please enter a valid phone number.Format: (000) 000-0000.

Relationship to patient

Other

Select your commercial health insurance company

I, the above named Patient or Responsible Party, acknowledge that I understand and agree that:

1. Rise Up Health Care (“Clinic”) is a participating provider with my insurance company (“Company”).

2. I am covered by one of the Company health insurance plans.

3. The health plan under which I am covered includes benefits for some or all of the services provided by Clinic.

4. Despite the above, I do not wish Clinic to submit a claim to Company for services provided to me by Clinic.

5. Until such time as I may otherwise advise Clinic in writing, I elect to pay for all services I receive from Clinic at their self-pay rates.

6. By electing to self-pay for services, any payments I make to Clinic will not be credited toward satisfying any deductible I may be subject to under my health insurance plan with Company unless otherwise permitted under the terms of my health plan.

I have read this Election to Self-Pay for Services form and have had the opportunity to ask any questions I may have had about the form. Any questions I may have had about this form have been answered to my satisfaction.

I have freely chosen to self-pay for services after having asked Clinic about payment options and having carefully considered those options.

Date

Signature of Patient or Responsible Party

Patient Election to Self-Pay for Services

Patient Information

Responsible Party

Consent to Waive Insurance